Michael A. Gisondi

Patient perspectives on communication with the medical team: Pilot study using the communication assessment tool-team (CAT-T)

OBJECTIVEnEffective communication is an essential aspect of high-quality patient care and a core competency for physicians. To date, assessment of communication skills in team-based settings has not been well established. We sought to tailor a psychometrically validated instrument, the Communication Assessment Tool, for use in Team settings (CAT-T), and test the feasibility of collecting patient perspectives of communication with medical teams in the emergency department (ED).nnnMETHODSnA prospective, cross-sectional study in an academic, tertiary, urban, Level 1 trauma center using the CAT-T, a 15-item instrument. Items were answered via a 5-point scale, with 5 = excellent. All adult ED patients (> or = 18 y/o) were eligible if the following exclusion criteria did not apply: primary psychiatric issues, critically ill, physiologically unstable, non-English speaking, or under arrest.nnnRESULTSn81 patients were enrolled (mean age: 44, S.D. = 17; 44% male). Highest ratings were for treating the patient with respect (69% excellent), paying attention to the patient (69% excellent), and showing care and concern (69% excellent). Lowest ratings were for greeting the patient appropriately (54%), encouraging the patient to ask questions (54%), showing interest in the patients ideas about his or her health (53% excellent), and involving the patient in decisions as much as he or she wanted (53% excellent).nnnCONCLUSIONnAlthough this pilot study has several methodological limitations, it demonstrates a signal that patient assessment of communication with the medical team is feasible and offers important feedback. Results indicate the need to improve communication in the ED.nnnPRACTICE IMPLICATIONSnIn the ED, focusing on the medical team rather then individual caregivers may more accurately reflect patients experience.

Socioeconomic Disparities Are Negatively Associated with Pediatric Emergency Department Aftercare Compliance

OBJECTIVESnThis study sought to identify demographic, socioeconomic, and clinical predictors of aftercare noncompliance by pediatric emergency department (ED) patients.nnnMETHODSnThe authors conducted a prospective, observational study of pediatric patients presenting to a university teaching hospital ED from July 1, 2002, through August 31, 2002. Demographic and clinical information was obtained from guardians during the ED visit. Guardians were contacted after discharge to determine compliance with ED aftercare instructions. Subjects were excluded if they were admitted or if guardians were unavailable or unwilling to consent. Data were analyzed using multivariable logistic regression to identify predictors of noncompliance from a list of predetermined variables.nnnRESULTSnOf the 409 patients enrolled in the study, 111 were prescribed medications and 364 were given specific follow-up instructions. Subtypes of the variable insurance status were significantly associated with medication noncompliance in multivariable regression analysis. Insurance status and low-acuity discharge diagnoses were significantly associated with follow-up noncompliance.nnnCONCLUSIONSnDisparity in health insurance has been shown to be a predictor of poor aftercare compliance for pediatric ED patients within the patient population.

A Case for Education in Palliative and End-of-life Care in Emergency Medicine

I n this issue of Academic Emergency Medicine, a resident author vividly describes the challenging case of a conscious patient who presents with an acute, catastrophic, nonsurvivable illness. This portfolio submission recounts an unenviable task that, while uncommon, is a shared experience of most emergency physicians (EPs): providing a prognosis of impending death to an unsuspecting patient. Communicating such horrific information is a high-stakes event—physicians never have a second chance to deliver that bad news differently or better. I commend the author for doing an excellent job when faced with this duty for this first time. Clearly the resident exhibited empathy and professional competence that will be remembered by the patient’s family members for years to come. Although the resident performed well in this case, the reflection highlights the need to improve the training of EPs in the domains of palliative and end-of-life care. The author considers, ‘‘how many times I had done scripted bad news notification . . . [but] this situation was so drastically different . . . death had not occurred but was certain and near.’’ The implication is that this clinical case was uncharted territory for which the resident had not been adequately prepared. What if the case did not result in such a rewarding, positive patient interaction? What if the resident had performed poorly? How would such an outcome affect the remainder of the resident’s training and future care in similar situations? Although a negative clinical experience can at times result in provider growth and maturation, a high-stakes error can be paralyzing for some residents. Training in palliative medicine and end-of-life care augments the natural humanism of a provider with deliberate, formal education in topics germane to the care of patients with life-threatening or severe advanced illness. Palliative medicine seeks to alleviate suffering and promote quality of life. Principles of palliative medicine can be applied in the emergency department (ED) to address the various forms of physical, psychological, social, and spiritual suffering associated with terminal disease. Primary skills of palliative care for emergency providers include treatment of pain and other symptoms common at the end of life, delivery of bad news, and assistance to patients and family members trying to cope with urgent and difficult treatment decisions. Four core cognitive domains of palliative medicine are evident in the case recounted in the resident portfolio: 1) death trajectories, 2) prognostication, 3) breaking bad news, and 4) goals of care.

Characteristics of pediatric trauma transfers to a level i trauma center: implications for developing a regionalized pediatric trauma system in california.

BACKGROUNDnsince California lacks a statewide trauma system, there are no uniform interfacility pediatric trauma transfer guidelines across local emergency medical services (EMS) agencies in California. This may result in delays in obtaining optimal care for injured children.nnnOBJECTIVESnthis study sought to understand patterns of pediatric trauma patient transfers to the study trauma center as a first step in assessing the quality and efficiency of pediatric transfer within the current trauma system model. Outcome measures included clinical and demographic characteristics, distances traveled, and centers bypassed. The hypothesis was that transferred patients would be more severely injured than directly admitted patients, primary catchment transfers would be few, and out-of-catchment transfers would come from hospitals in close geographic proximity to the study center.nnnMETHODSnthis was a retrospective observational analysis of trauma patients ≤ 18 years of age in the institutional trauma database (2000-2007). All patients with a trauma International Classification of Diseases, 9th revision (ICD-9) code and trauma mechanism who were identified as a trauma patient by EMS or emergency physicians were recorded in the trauma database, including those patients who were discharged home. Trauma patients brought directly to the emergency department (ED) and patients transferred from other facilities to the center were compared. A geographic information system (GIS) was used to calculate the straight-line distances from the referring hospitals to the study center and to all closer centers potentially capable of accepting interfacility pediatric trauma transfers.nnnRESULTSnof 2,798 total subjects, 16.2% were transferred from other facilities within California; 69.8% of transfers were from the catchment area, with 23.0% transferred from facilities ≤ 10 miles from the center. This transfer pattern was positively associated with private insurance (risk ratio [RR] = 2.05; p < 0.001) and negatively associated with age 15-18 years (RR = 0.23; p = 0.01) and Injury Severity Score (ISS)u2003> 18 (RR = 0.26; p < 0.01). The out-of-catchment transfers accounted for 30.2% of the patients, and 75.9% of these noncatchment transfers were in closer proximity to another facility potentially capable of accepting pediatric interfacility transfers. The overall median straight-line distance from noncatchment referring hospitals to the study center was 61.2 miles (IQR = 19.0-136.4), compared to 33.6 miles (IQR = 13.9-61.5) to the closest center. Transfer patients were more severely injured than directly admitted patients (p < 0.001). Out-of-catchment transfers were older than catchment patients (p < 0.001); ISS > 18 (RR = 2.06; p < 0.001) and age 15-18 (RR = 1.28; p < 0.001) were predictive of out-of-catchment patients bypassing other pediatric-capable centers. Finally, 23.7% of pediatric trauma transfer requests to the study institution were denied due to lack of bed capacity.nnnCONCLUSIONSnfrom the perspective an adult Level I trauma center with a certified pediatric intensive care unit (PICU), delays in definitive pediatric trauma care appear to be present secondary to initial transport to nontrauma community hospitals within close proximity of a trauma hospital, long transfer distances to accepting facilities, and lack of capacity at the study center. Given the absence of uniform trauma triage and transfer guidelines across state EMS systems, there appears to be a role for quality monitoring and improvement of the current interfacility pediatric trauma transfer system, including defined triage, transfer, and data collection protocols.

Examining Emergency Department Communication Through a Staff-Based Participatory Research Method: Identifying Barriers and Solutions to Meaningful Change

STUDY OBJECTIVEnWe test an initiative with the staff-based participatory research (SBPR) method to elicit communication barriers and engage staff in identifying strategies to improve communication within our emergency department (ED).nnnMETHODSnED staff at an urban hospital with 85,000 ED visits per year participated in a 3.5-hour multidisciplinary workshop. The workshop was offered 6 times and involved: (1) large group discussion to review the importance of communication within the ED and discuss findings from a recent survey of patient perceptions of ED-team communication; (2) small group discussions eliciting staff perceptions of communication barriers and best practices/strategies to address these challenges; and (3) large group discussions sharing and refining emergent themes and suggested strategies. Three coders analyzed summaries from group discussions by using latent content and constant comparative analysis to identify focal themes.nnnRESULTSnA total of 127 staff members, including attending physicians, residents, nurses, ED assistants, and secretaries, participated in the workshop (overall participation rate 59.6%; range 46.7% to 73.3% by staff type). Coders identified a framework of 4 themes describing barriers and proposed interventions: (1) greeting and initial interaction, (2) setting realistic expectations, (3) team communication and respect, and (4) information provision and delivery. The majority of participants (81.4%) reported that their participation would cause them to make changes in their clinical practice.nnnCONCLUSIONnInvolving staff in discussing barriers and facilitators to communication within the ED can result in a meaningful process of empowerment, as well as the identification of feasible strategies and solutions at both the individual and system levels.

Impact of Burnout on Self-Reported Patient Care Among Emergency Physicians

Introduction Burnout is a syndrome of depersonalization, emotional exhaustion and sense of low personal accomplishment. Emergency physicians (EPs) experience the highest levels of burnout among all physicians. Burnout is associated with greater rates of self-reported suboptimal care among surgeons and internists. The association between burnout and suboptimal care among EPs is unknown. The objective of the study was to evaluate burnout rates among attending and resident EPs and examine their relationship with self-reported patient care practices. Methods In this cross-sectional study burnout was measured at two university-based emergency medicine residency programs with the Maslach Burnout Inventory. We also measured depression, quality of life (QOL) and career satisfaction using validated questionnaires. Six items assessed suboptimal care and the frequency with which they were performed. Results We included 77 out of 155 (49.7%) responses. The EP burnout rate was 57.1%, with no difference between attending and resident physicians. Residents were more likely to screen positive for depression (47.8% vs 18.5%, p=0.012) and report lower QOL scores (6.7 vs 7.4 out of 10, p=0.036) than attendings. Attendings and residents reported similar rates of career satisfaction (85.2% vs 87.0%, p=0.744). Burnout was associated with a positive screen for depression (38.6% vs 12.1%, p=0.011) and lower career satisfaction (77.3% vs 97.0%, p=0.02). EPs with high burnout were significantly more likely to report performing all six acts of suboptimal care. Conclusion A majority of EPs demonstrated high burnout. EP burnout was significantly associated with higher frequencies of self-reported suboptimal care. Future efforts to determine if provider burnout is associated with negative changes in actual patient care are necessary.

Scholarly Tracks in Emergency Medicine

Over the past decade, some residency programs in emergency medicine (EM) have implemented scholarly tracks into their curricula. The goal of the scholarly track is to identify a niche in which each trainee focuses his or her scholarly work during residency. The object of this paper is to discuss the current use, structure, and success of resident scholarly tracks. A working group of residency program leaders who had implemented scholarly tracks into their residency programs collated their approaches, implementation, and early outcomes through a survey disseminated through the Council of Emergency Medicine Residency Directors (CORD) list-serve. At the 2009 CORD Academic Assembly, a session was held and attended by approximately 80 CORD members where the results were disseminated and discussed. The group examined the literature, discussed the successes and challenges faced during implementation and maintenance of the tracks, and developed a list of recommendations for successful incorporation of the scholarly track structure into a residency program. Our information comes from the experience at eight training programs (five 3-year and three 4-year programs), ranging from 8 to 14 residents per year. Two programs have been working with academic tracks for 8 years. Recommendations included creating clear goals and objectives for each track, matching track topics with faculty expertise, protecting time for both faculty and residents, and providing adequate mentorship for the residents. In summary, scholarly tracks encourage the trainee to develop an academic or clinical niche within EM during residency training. The benefits include increased overall resident satisfaction, increased success at obtaining faculty and fellowship positions after residency, and increased production of scholarly work. We believe that this model will also encourage increased numbers of trainees to choose careers in academic medicine.

Palliative Care Symptom Assessment for Patients with Cancer in the Emergency Department: Validation of the Screen for Palliative and End-of-Life Care Needs in the Emergency Department Instrument

OBJECTIVEnWe sought to develop and validate a novel palliative medicine needs assessment tool for patients with cancer in the emergency department.nnnMETHODSnAn expert panel trained in palliative medicine and emergency medicine reviewed and adapted a general palliative medicine symptom assessment tool, the Needs at the End-of-Life Screening Tool. From this adaptation a new 13-question instrument was derived, collectively referred to as the Screen for Palliative and End-of-life care needs in the Emergency Department (SPEED). A database of 86 validated symptom assessment tools available from the palliative medicine literature, totaling 3011 questions, were then reviewed to identify validated test items most similar to the 13 items of SPEED; a total of 107 related questions from the database were identified. Minor adaptations of questions were made for standardization to a uniform 10-point Likert scale. The 107 items, along with the 13 SPEED items were randomly ordered to create a single survey of 120 items. The 120-item survey was administered by trained staff to all patients with cancer who met inclusion criteria (age over 21 years, English-speaking, capacity to provide informed consent) who presented to a large urban academic emergency department between 8:00 am and 11:00 pm over a 10-week period. Data were analyzed to determine the degree of correlation between SPEED items and the related 107 selected items from previously validated tools.nnnRESULTSnA total of 53 subjects were enrolled, of which 49 (92%) completed the survey in its entirety. Fifty-three percent of subjects were male, age range was 24-88 years, and the most common cancer diagnoses were breast, colon, and lung. Cronbach coefficient α for the SPEED items ranged from 0.716 to 0.991, indicating their high scale reliability. Correlations between the SPEED scales and related assessment tools previously validated in other settings were high and statistically significant.nnnCONCLUSIONnThe SPEED instrument demonstrates reliability and validity for screening for palliative care needs of patients with cancer presenting to the emergency department.

Evaluating educational interventions in emergency medicine.

This article presents the proceedings of the 2012 Academic Emergency Medicine consensus conference breakout group charged with identifying areas necessary for future research regarding effectiveness of educational interventions for teaching emergency medicine (EM) knowledge, skills, and attitudes outside of the clinical setting. The objective was to summarize both medical and nonmedical education literature and report the consensus formation methods and results. The authors present final statements to guide future research aimed at evaluating the best methods for understanding and developing successful EM curricula using all types of educational interventions.

Should You Close Your Waiting Room? Addressing ED Overcrowding Through Education and Staff-Based Participatory Research

INTRODUCTIONnThe purpose of this project was to develop operational criteria to close the ED waiting room.nnnMETHODSnA prospective, staff-based participatory research model was used. Nurses at an urban ED with 70,000 visits attended a four-hour workshop concerning ED overcrowding. The workshops consisted of two parts, (1) educational sessions that reviewed key concepts of ED overcrowding, followed by (2) discussions of a proposal to close the waiting room as a means to decrease overcrowding. During the discussions, nurses were asked to develop guidelines to safely and consistently close the waiting room. The investigators defined the waiting room as closed when (1) ambulatory patients could be taken directly to a room or hallway space for bedside triage, registration, and initiation of care, or (2) patients were triaged in the waiting room and then taken directly to a care space for registration at the bedside. The primary outcome measure of the project was the development of guidelines to open (use) or close (not use) the ED waiting room.nnnRESULTSnSeventy three of 100 nurses participated in the workshops. ED waiting room closure criteria were developed as 4 Questions to Guide the Use of the Waiting Room. These dichotomous (yes/no) questions reflected issues of available staff, available care space (traditional ED bed spaces and designated hall spaces), patient acuity, and additional surge capacity.nnnDISCUSSIONnStaff-based participatory research was an effective method to design an operational change. Nurses developed four explicit criteria describing when the waiting room should be closed.